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| Montana Administrative Register Notice 6-286 | No. 3 02/09/2024 | |
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BEFORE THE COMMISSIONER OF SECURITIES AND INSURANCE OFFICE OF THE MONTANA STATE AUDITOR
TO: All Concerned Persons
1. The Commissioner of Securities and Insurance, Office of the Montana State Auditor (CSI) proposes to amend, repeal, and adopt the above-stated rules.
2. The 68th Montana Legislature passed House Bill 156, which transferred the authority and operation of the Managed Care Plan Network Adequacy and Quality Assurance Act from the Department of Public Health and Human Services (DPHHS) to CSI. The first step in implementing the relevant sections of HB 156 occurred on October 20, 2023, when the commissioner published MAR Notice No. 6-283, which, effective January 1, 2024, transferred rules pertaining to Quality Assurance for Managed Care Plans from DPHHS to CSI. The second step in implementing the relevant sections of HB 156 is amending the rules to conform to the changes made by HB 156 and to CSI operations, which is accomplished by the amendments proposed in this notice.
3. CSI will make reasonable accommodations for persons with disabilities who wish to participate in this rulemaking process or need an alternative accessible format of this notice. If you require accommodation, contact CSI no later than 5:00 p.m. on February 20, 2024, to advise us of the nature of the accommodation that you need. Please contact Laura Shirtliff, Digital and Creative Services Director, 840 Helena Avenue, Helena, Montana, 59601; telephone (406) 444-2040 or 1-800-3326148; fax (406) 444-3413; TDD (406) 444-3246; or e-mail [email protected].
4. The rules as proposed to be amended provide as follows, new matter underlined, deleted matter interlined:
6.6.8901 PURPOSE (1) The purpose of these rules is to implement the quality assurance provisions of the Montana Managed Care Plan Network Adequacy and Quality Assurance Act specified in Title 33, chapter 36, part 3, MCA. These rules establish mechanisms for the
AUTH: 33-36-105, MCA IMP: 33-36-102, MCA
6.6.8905 QUALITY ASSURANCE STRUCTURE AND ACCREDITATION (1) The health carrier shall appoint, prior to commencing operation, a medical physician licensed to practice in the state of Montana to advise, oversee, and actively participate in the implementation and operation of the quality assurance program. (2) The health carrier may delegate quality assurance activities. The health carrier shall retain responsibility for the performance of all delegated activities and shall develop and implement review and reporting requirements to (3) A health carrier whose managed care quality assurance plan has been accredited by a nationally recognized accrediting organization shall initially provide a copy of the accreditation certificate or outcome report and the accrediting standards used by the accrediting organization to the (a) If the (b) After approval by the (c) (d) The
AUTH: 33-36-105, MCA IMP: 33-36-105, 33-36-302, MCA
6.6.8906 WRITTEN DESCRIPTION OF QUALITY ASSESSMENT PLAN (1) The health carrier shall implement a written quality assessment plan that is evaluated annually and updated as necessary. The plan must be submitted to the (a) the plan's mission, goals, and objectives; (b) the plan's organizational structure and the job titles of the personnel responsible for quality assessment; (c) the scope of the quality assessment plan's activities, including: (i) specific diagnoses, conditions, or treatments targeted for review to improve health care services and health outcomes; (ii) mechanisms to evaluate enrollees' health and health care services in relation to current medical research, knowledge, standards, and practices; (iii) communication processes by which the findings generated by the quality assessment program are communicated to providers and consumers to improve the health of enrollees; and (iv) mechanisms to evaluate the service performance of the health carrier and primary care physicians. (2) The written quality assessment plan must be signed by the health carrier's corporate officer certifying that the plan meets the (3) The
AUTH: 33-36-105, MCA IMP: 33-36-105, 33-36-302, MCA
6.6.8907 COMPONENTS OF QUALITY ASSESSMENT ACTIVITIES (1) Annually, the health carrier shall evaluate its quality assessment activities by using the following (a) childhood immunization; (b) breast cancer screening; (c) cervical cancer screening; (d) comprehensive diabetes care; and (e) HEDIS/Consumer Assessment of Health Plan Survey (CAHPS) for adults. (2) The health carrier shall record organizational components that affect accessibility, availability, comprehensiveness, and continuity of care, including: (a) referrals; (b) case management; (c) discharge planning; (d) appointment scheduling and waiting periods for all types of health care services; (e) second opinions, as applicable; (f) prior authorizations, as applicable; (g) provider reimbursement arrangements that contain financial incentives that may affect the care provided; and (h) other systems, procedures, or administrative requirements used by the health carrier that affect the delivery of care. (3) The health carrier may meet the requirements in (2) by submitting information to the (4) The
AUTH: 33-36-105, MCA IMP: 33-36-105, 33-36-302, MCA
6.6.8910 QUALITY IMPROVEMENT (1) (a) ongoing monitoring of process, structure, and outcomes of patient care or clinical performance; (b) evaluation of the data collected from ongoing monitoring activities to identify problems in patient care or clinical performance using criteria developed and applied by health care professionals; (c) measurable objectives for each improvement action within the reporting year, including the degree of expected change in persons or situations; (d) time frames for quality improvement action; and (e) parties responsible for implementing quality improvement action.
AUTH: 33-36-105, MCA IMP: 33-36-105, 33-36-303, MCA
6.6.8911 CLINICAL FOCUSED STUDY (1) The health carrier shall conduct a focused study relevant to the quality of its services for enrollee care. The health carrier must document the clinical focused study and submit it to the (2) The health carrier shall select topics for the focused study that are justified based on any of the following considerations: (a) areas of high volume; (b) areas of high risk; (c) areas where problems are expected or where they have occurred in the past; (d) areas that can be corrected or where prevention may have an impact; (e) areas that have potential adverse health outcomes; and (f) areas where enrollee complaints have occurred. (3) The health carrier shall document the study methodology employed, including: (a) the focused study question; (b) the sample selection; (c) data collection; (d) evaluation criteria; and (e) measurement techniques.
AUTH: 33-36-105, MCA IMP: 33-36-303, MCA
6.6.8915 ENROLLEE COMPLAINT SYSTEM (1) The health carrier shall have an internal complaint system for enrollees. Such a system shall comply with the requirements of 33-31-303, MCA (2) The health carrier shall conduct ongoing evaluations of all enrollee complaints, including complaints about the health carrier's services filed with participating providers. Ongoing evaluations must be conducted in accordance with ARM (3) Evaluation methods must permit the health carrier to track specific complaints, assess trends, and establish that corrective action is implemented and effective in improving the identified problem(s). (4) The health carrier shall document and monitor the effectiveness of its evaluation of the enrollee complaint system and communicate it to the involved providers, enrollees, and the
AUTH: 33-36-105, MCA IMP: 33-36-303, MCA
6.6.8916 RECORDING CONSUMER SATISFACTION (1) The health carrier shall record consumer components that identify enrollees' perceptions on the quality of the health carrier's services, including: (a) enrollee satisfaction surveys; and (b) enrollee complaints, including: (i) the health carrier's resolution of the complaints through its internal procedures;
(2) The health carrier shall submit documentation of its handling of consumer satisfaction to the (3) The health carrier may meet the requirements in (1)(a) (4) The identities of enrollees involved in recording consumer satisfaction are subject to the confidentiality requirements provided in 33-36-305, MCA.
AUTH: 33-36-105, MCA IMP: 33-36-303, MCA
5. CSI proposes to repeal the following rules:
6.6.8920 CORRECTIVE ACTION
AUTH: 33-36-105, MCA IMP: 33-36-105, 33-36-401, MCA
6.6.8921 INFORMAL RECONSIDERATION OF DEPARTMENT DECISION
AUTH: 33-36-105, MCA IMP: 33-36-401, MCA
6. The rule proposed to be adopted is as follows:
NEW RULE I NOTICE OF DISAGREEMENT AND PROGRESSION TO ENFORCEMENT ACTION (1) If a health carrier disagrees with a corrective action recommended by the commissioner pursuant to 33-36-401(1), MCA, the health carrier must provide a written notice to the commissioner containing a short and plain statement of the grounds for disagreement with the corrective action. (2) Once the carrier provides written notice to the commissioner pursuant to this rule, the matter proceeds as an enforcement action for non-compliance pursuant to 33-36-401(2)(a), MCA. The enforcement action will be held in accordance with the Montana Administrative Procedure Act, Title 2, chapter 4, part 6, MCA, and ARM 6.2.101.
AUTH: 33-36-105, MCA IMP: 33-36-401, MCA
7. REASON: The Commissioner of Securities and Insurance, Montana State Auditor, Troy Downing (commissioner) is the statewide elected official responsible for administering the Montana Insurance Code and regulating business of insurance. These amendments are necessary to ensure compliance with the Managed Care Plan Network Adequacy and Quality Assurance Act, the administration of which was transferred from DPHHS to CSI by House Bill 156, enacted by the 68th Montana Legislature. The above-stated amendments conform the already-existing rules to the changes made by HB 156 and to CSI's operations.
8. Concerned persons may submit their data, views, or arguments concerning the proposed actions in writing to: Laura Shirtliff, Digital and Creative Services Director, 840 Helena Avenue, Helena, Montana, 59601; telephone (406) 444-2040 or 1-800-332-6148; fax (406) 444-3413; TDD (406) 444-3246; or e-mail [email protected], and must be received no later than 5:00 p.m., March 8, 2024.
9. If persons who are directly affected by the proposed actions wish to express their data, views, or arguments orally or in writing at a public hearing, they must make written request for a hearing and submit this request along with any written comments to Laura Shirtliff at the above address no later than 5:00 p.m., March 8, 2024.
10. If the agency receives requests for a public hearing on the proposed actions from either 10 or 25 percent, whichever is less, of the persons directly affected by the proposed actions; from the appropriate administrative rule review committee of the Legislature; from a governmental subdivision or agency; or from an association having not less than 25 members who will be directly affected, a hearing will be held at a later date. Notice of the hearing will be published in the Montana Administrative Register. Ten percent of those directly affected has been determined to be 10 persons based on a conservative estimate of managed care members.
11. CSI maintains a list of interested persons who wish to receive notices of rulemaking actions proposed by this agency. Persons who wish to have their name added to the list must make a written request that includes the name, e-mail, and mailing address of the person to receive notices and specifies for which program the person wishes to receive notices. Notices will be sent by e-mail unless a mailing preference is noted in the request. Written requests may be mailed or delivered to the contact person in paragraph 8 or made by completing a request form at any rules hearing held by CSI.
12. An electronic copy of this proposal notice is available through the Secretary of State's website at http://sosmt.gov/ARM/Register.
13. The bill sponsor contact requirements of 2-4-302, MCA, do not apply.
14. With regard to the requirements of 2-4-111, MCA, CSI has determined that the amendment, repeal, and adoption of the above-referenced rules will not significantly and directly impact small businesses.
/s/ Ole Olson /s/ Mary Belcher Ole Olson Mary Belcher Rule Reviewer Deputy Auditor Commissioner of Securities and Insurance, Office of the Montana State Auditor
Certified to the Secretary of State January 30, 2024.
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